1) Palliative care practices developed in Western countries can be adapted to be culturally sensitive when working with Muslim patients in Jordan. 2) It is important to involve the whole family in decision making, accept the patient's religious obligations before death, and focus on relieving suffering rather than false hope when discussing prognosis. 3) Euphemisms about a patient being in a "critical condition" are better received than time estimates when discussing prognosis with traditional Muslim families in Jordan.

1. JOURNAL OF PALLIATIVE MEDICINE
Volume 11, Number 10, 2008 Letters to the Editor
© Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2008.0166
Palliative Care in Jordan: Culturally Sensitive Practice
Mohammad Bushnaq, M.D.
Dear Editor: open discussion, and the patient was discharged home with
our home palliative care service. Three weeks later the pa-
At the King Hussein Cancer Center in Jordan, we have tient died at home peacefully.
been working since 2000 to implement palliative care for pa- This case illustrates that approaches developed in Europe
tients with cancer. We have been taught using materials from and the United States can be integrated into traditional Arab
the EPEC Project, the ELNEC Project, and onsite teaching by culture. We think its clear that values and principles of pal-
teams of physicians and nurses from the United States as liative care are the same everywhere, but the way we apply
well as training at San Diego Hospice and the Institute for it needs to be tailored to local culture and norms. In this ex-
Palliative Medicine. ample, in response to his question, “How long have I got?”
As part of our implementation, an important question we did not answer with the phrase, “Weeks to months’ as
arose. How do we apply what we learned in palliative care we might if we had been practicing in California.
in harmony with our culture? Let me illustrate with a recent We have the following advice for those working in Arab
case. and Muslim culture.
A 52-year-old man presented with pallor, fatigue, and
jaundice due to pancreatic cancer metastatic to the liver. He • The family system is strong. Parents, spouses, and elder
was married and had three daughters. He was a devout Mus- children are involved in making decisions. They need to
lim. be assured that we respect their opinion and input.
After investigation, the oncologist decided there were no • Traditional Muslims believe the patient must attend to
curative measures and he referred the patient to palliative some moral and religious obligations before death.
care. At the time the palliative care team arrived in the pa- • When facing suffering and illness, a traditional Muslim
tient’s room, many family members were waiting outside the accepts suffering as a way of atonement of one’s sins. This
room with many questions. They said they hoped they will doesn’t conflict with giving all efforts to relieve suffering.
find a treatment somewhere else. They asked that the patient This way of handling suffering helps the Muslim cope
not know anything about his disease to keep up his morale with the illness and to die in peace with self, God, and
and spirit. The atmosphere was tense. others.
We asked the close family for a “family meeting,” in which • When we ask patients if they want to hear the truth when
we listened to them talking about the disease progression, we are “breaking bad news,” most of the people say yes.
their feelings, hopes, and their expectations from us. Then But, we subsequently discover that they wish they did not
we shared the disease condition and prognosis. ask. We discovered most are seeking reassurance and em-
In Jordan, based in the Islamic religion and cultural norms, pathy rather than information, even though they answer
people believe that no matter what you do, when your time “yes.” Our approach now is to respond to the patient’s
comes to die, it is God’s wish and your destiny. Therefore, question with a more oblique answer. We try to switch
it was easy for the family to accept a do-not-resuscitate con- their focus toward quality of life and comfort, without of-
cept. And in the same way, they accepted the fact that it is fering false hope. In rare occasions, when the patient in-
the right of the patient to at least have some sense that his sists to know, we give the answer following the six steps
death is near, so that he could finish “unfinished business,” of breaking bad news advocated by Robert Buckman.
in particular moral and religious duties, so that he may meet • When asked about prognosis, in our experience, tradi-
his lord free of sins. tional Muslims respond well to euphemisms. Instead of
Then, we asked the family to join us to see the patient to- giving answers in terms of time, we say that he/she is re-
gether. We talked about his cancer, emphasizing that the goal ally in a critical condition, and it is the right time for him
now will be for symptom control and quality of life. He lis- to meet his family and to prepare for the hereafter in case
tened carefully and then he asked: how much time do I have? he/she deteriorates. This prompts the family to move into
We answered, “We don’t have a definite answer, but we do their traditional role, sometimes with our help, to stay at
recommend you balance things. At the same time you have the bedside, reading a chapter from Noble Qur’an and to
hope to survive for a long time, you really need to get pre- prompt gently that the patient speak the shahadah; (bear-
pared. In other words, hope for the best and prepare for the ing witness that there is no true God but Allah and Mo-
worst.” The patient and the family were satisfied with this hammad is verily his servant and his messenger).
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2. 2 LETTERS TO THE EDITOR
• We do not present do-not-resuscitate status as a choice. to address spiritual needs with the patients at this stage
Patients and families tell us it is a big burden for them to of their life.
choose, and many family members said they would feel
guilty if they make that decision. Instead, we rely on our Address reprint requests to:
legal and religious background, and inform the family this Mohammad Bushnaq, M.D.
is a medical decision so they only need to be informed, Hospice and Palliative Care Consultant
not to decide. King Hussein Cancer Center
• Muslim people are not familiar with “chaplain,” since in Amman
Islam you can talk directly to God, and you do not need Jordan
anybody to help you pray. On the other hand, we found
that it is very useful to have somebody who has the skills E-mail: mbushnaq@khcc.jo